Job Description Summary

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Responsible for participating in clinical audit activities for Carelon Health.

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How will you make an impact & Requirements

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Clinical Auditor

Responsible for participating in clinical audit activities for Carelon Health.

Primary duties may include but are not limited to:

• Conduct audits of the work done by Carelon Health nursing staff and appeals.

• Reviews clinical cases documentation (i.e. letters) claims history provider information and benefit information.

• Utilizes multiple sources to conduct research including mainframe applications and business standard operating procedures.

• Documents results and finding and provides scored results to clinical nurses and management.

• Prepares reports for management that define and evaluate problems and propose solutions.

• Handles rebuttals for assigned cases and for other clinical audit staff.

• Attends weekly quality meetings and participates in quarterly calibration meetings.

• Assists with clinical cases.

Requirements:

• Requires AS in Nursing

• Minimum of 3 years of clinical experience in a healthcare setting; or any combination of education and experience which would provide an equivalent background.

• Current unrestricted RN license in applicable state(s) required.

• Knowledge of and experience with regulatory/accreditation standards/audits strongly preferred.

• BSN preferred in addition to CPHQ (Certified Professional in Healthcare Quality)

Compensation: $74,160K – $111,240K annual salary & bonus eligible

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